Provider Demographics
NPI:1205357886
Name:GROSS, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S BROAD ST APT 412
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-2509
Mailing Address - Country:US
Mailing Address - Phone:305-773-6137
Mailing Address - Fax:
Practice Address - Street 1:777 S BROAD ST APT 412
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-2509
Practice Address - Country:US
Practice Address - Phone:305-773-6137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-04
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4590942084N0400X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology